Provider Self-Audit Reporting Form

Provider Self-Audit Reporting Form

Please complete all sections of this form to report self initiated payback to Trillium Health Resources based on out of compliance issues found during a Voluntary Self Audit conducted at your provider agency.

Instructions on how to complete an adjustment/void can be found on Trillium’s website in the Provider Documents and Forms as the Trillium Replacement and Voided Claims Process.

Date of Submission

Provider Name*

Provider Address*

Provider NPI Number*

Provider Contact Name*

Provider Contact Email*

Related Case*

Is the Self-Audit in relation to an open case with Trillium?

Select

If yes above, Case Number?

Identified Problem*

What were the issue(s) found during the Self-Audit?

Date of Services Included in Self-Audit*

What was the date of service reviewed or date range of services reviewed during your Self-Audit?

What records were reviewed? *

Description of what information was reviewed during the Self-Audit.

Findings *

What was the outcome of the Self-Audit?

Actions Taken *

Based on the outcome of the Self-Audit, what actions were taken to remedy the problems found including change in policies, procedures and/or process.

Void/Replacement Claim Type*

How will your agency be replacing/voiding the claims paid in error?

Select

Self-Audit Document Submissions*

The following items may be attached if applicable:

Completed Self- Audit Replacement/Void Claims Chart, if provider submits replacement/voided claims.
Any other document supporting the Self-Audit.

Drag and drop files here or

Send me a copy of my responses

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